Contrast media

 The frequency of allergic-like and physiologic adverse events related

to the intravascular administration of iodinated contrast media (ICM)
is low and has decreased considerably with changes in usage from
(HOCM) to (LOCM).
 Severe and potentially life-threatening adverse events continue to
occur rarely and unpredictably. 
 Nearly all life-threatening contrast reactions occur within the first
20 minutes after contrast medium injection.
Acute Adverse Events

 Can be either allergic-like or physiologic.

 Standardized classification system is important to minimize variation between
published reports.
 The management of patients experiencing these reaction types is different.
Allergic-Like Reactions

 Manifest similarly to true allergic reactions seen with other drugs and
allergens.
 Antigen-Antibody response cannot be always identified
 Classified as “anaphylactoid”, “allergic-like”, or “idiosyncratic”.
 Independent of dose and concentration above a certain unknown threshold.
Pathogenesis

 May involve activation, deactivation, or inhibition of a variety of vasoactive

substances or mediators (such as histamine, complement, and the kinin
system).
 Skin and intradermal testing are positive in a minority of individuals.

 Additives or contaminants has also been suggested as a cause.

 Rubber or calcium chelators.
Physiologic Reactions

 Relate to specific molecular attributes that lead to direct chemotoxicity,

osmotoxicity, or molecular binding to certain activators.
 Are dose and concentration dependent.
Pathogenesis

 Contrast media-related hyperosmolality and/or calcium binding leading to

functional hypocalcemia.
 Cardiac arrhythmias, depressed myocardial contractility, cardiogenic pulmonary
edema, and seizures.
 Vasovagal reactions.
 May be related to anxiety. 
 Characterized by:
 Hypotension with Bradycardia.
 Feeling of apprehension and accompanying diaphoresis.
Acute Adverse Events

Allergic-Like Reactions Physiologic Reactions

 Independent of dose and  Are dose and concentration
concentration dependent.
 Pathophysiology:  Pathophysiology:
 activation, deactivation, or inhibition of  Contrast media hyperosmolality
a variety of vasoactive substances or and/or calcium binding.
mediators.
 Vasovagal reactions.
 Due to Additives or contaminants.
 Premedication decrease recurrence
 Premedication have no affect
rate. on recurrence rate.
Reaction Severity

 Assessment of reaction severity is somewhat subjective, and it is difficult to

succinctly describe all possible degrees of reaction severity.
Sever Reaction

 Signs and symptoms are often life-threatening and can result in permanent
morbidity or death if not managed appropriately.
 If it is unclear what etiology caused the cardiopulmonary arrest, assume that
the reaction is/was an allergic-like one.
Incidence

 Underreporting and variation in the classification of acute adverse reactions

have affected the reported incidence of these events.
 HOCM: 5% to 15%
 LOCM are associated with a very low incidence of acute adverse events , 0.2%-
0.7%.
 Serious acute reactions to IV LOCM are rare, with an historical rate of
approximately four in 10,000 (0.04%).
Common Risk Factors for Acute Contrast
Reactions
 Most contrast reactions remain sporadic and unpredictable.
 The effects of dose, route , and rate of delivery of contrast media on the incidence of adverse
events are not entirely clear.
 “Test Injection” does not decrease the incidence of severe allergic-like reactions. However it may increase
it .
Common Risk Factors for Acute
Contrast Reactions
 A prior allergic-like reaction to ICM is the most substantial risk factor for a
recurrent allergic-like adverse event.
ü 5-fold increased risk of developing a future allergic-like reaction if exposed to the
same class of contrast medium again.
ü Estimated to range from 10 to 35% (non-premedicated) and 10% (premedicated).
ü Prior allergic-like reaction to GBCM are at no greater risk for allergic-like
reaction to ICM.
Common Risk Factors for
Acute Contrast Reactions
 Atopic and asthmatics individuals.
ü unrelated allergies are at a 2- to 3-fold increased risk of an allergic-like
contrast reaction.
ü Patients with shellfish or povidone-iodine (e.g., Betadine®) allergies are at no greater
risk 
ü Increase risk if take Beta- blocker ?merely indicated those patients with
more comorbid conditions.
Common Risk Factors for Acute
Contrast Reactions
 Pre-existing medical conditions.
 Cardiac Status > increased risk of a non-allergic cardiac event.

 Anxiety. 
 Reassuring an anxious patient before contrast medium injection may mitigate the
likelihood of a mild contrast reaction.
Common Risk Factors for Acute
Contrast Reactions
 Patients with Myasthenia Gravis.
 Relative contraindication to intravascular HCOM.
 Intravascular LOCM may be relatively contraindicated. (Somashekar et al [31] in 2013).

 Sickle-Cell Trait/Disease: 
 no evidence of increase the risk of an acute sickle crisis occurs with modern
iodinated or gadolinium-based contrast medium.
 Pheochromocytoma:
 no evidence that IV administration oincreases the risk of
hypertensive crisis in patients with pheochromocytoma
Common Risk Factors for Acute Contrast Reactions
Hyperthyroidism:

Precatioun should be taken in the setting of:

 Patients with acute thyroid storm.
 Can potentiate thyrotoxicosis; in such patients, iodinated contrast medium
should be avoided. 
 Corticosteroid premedication in this setting is unlikely to be helpful.
 Patients considering radioactive iodine therapy or in
patients undergoing radioactive iodine imaging of the
thyroid gland. 
 Can interfere with uptake of the treatment and diagnostic dose. 
 If iodinated contrast medium was administered, a washout period is
suggested. 
  Hyperthyroidism:3-4 weeks.  
 Hypothyroidism:6 weeks.
ADVERSE REACTIONS TO GADOLINIUM-
BASED CONTRAST MEDIA
 GBCM are extremely well tolerated by the vast majority of patients in whom
they are injected. 
 Acute adverse reactions are encountered with a lower frequency than is
observed after administration of iodinated contrast media.
Adverse Reactions

 Most reactions are mild and physiologic, including coldness, warmth, or pain
at the injection site; nausea with or without vomiting; headache;
paresthesias; and dizziness.
 Allergic- like reactions are uncommon and vary in frequency from 0.004% to –
0.7%.
 Severe life-threatening anaphylactic reactions occur but are exceedingly rare
(0.001% to 0.01%).
Risk Factors
 Previous reaction to GBCM.
 about eight times higher.
 use a different GBCM and premedicate for subsequent MR examinations
 gadobenate dimeglumine, has FDA labeling contraindicating its use in patients
who have a history of an allergic-like reaction to GBCM.
 GBCM that have been most commonly associated with NSF are less likely to be
associated with allergic-like reactions and vice versa.
 Patients with asthma and various other allergies.
 There is no cross-reactivity between GBCM and iodinated contrast media.
Patients with Sickle Cell Disease

 The risk to patients with sickle cell disease from IV-administered GBCM at
approved dosages is very low or nonexistent, and there is no reason to
withhold these agents from these patients when their use is otherwise
indicated.
 FDA package inserts suggested caution in patients with sickle cell disease for
two GBCM approved for use in the United States (gadoversetamide
[OptiMARK, Guerbet] and gadoteridol [Prohance, Bracco Diagnostics]).
Breath-holding Difficulty with
Gadoxetate Disodium
 Patients complained of subjective shortness of breath following gadoxetate
disodium compared to gadobenate dimeglumine exposure.
 The event is self-limited and does not appear to relate to allergic-like
bronchospasm.
 Corticosteroid prophylaxis is unlikely to be beneficial.
Breath-holding Difficulty with Gadoxetate Disodium
 Strong risk factors:
 larger administered volume irrespective of patient weight (20 mL
doses are twice as likely to cause the artifact as 10 mL doses)
 chronic obstructive pulmonary disease (patients with COPD have
a 35–40% event rate).
 previously similar reaction (previously affected patients have a
60% event rate on subsequent studies compared to a 5% event rate
in the unaffected population).
Corticosteroid Premedication
 The purpose of corticosteroid premedication is to mitigate the likelihood of
an allergic-like reaction in high- risk patients.
 Premedication does not prevent all contrast reactions.
 Allergic- like contrast reactions that occur despite premedication are called
“breakthrough reactions”.
 Physiologic reactions are not mitigated by premedication and are not considered
“breakthrough reactions,” even if they occur following premedication.
Premedication Strategies
 12- or 13-hour oral premedication maybe considered in the following settings:
1. Outpatient with a prior allergic-like or unknown-type contrast reaction to the same
class of contrast medium .
2. Emergency department patient or inpatient with a prior allergic-like or unknown-
type contrast reaction to the same class of contrast medium in whom the use of
premedication is not anticipated to adversely delay care decisions or treatment.
 Accelerated IV premedication may be considered in the following settings:
1. Outpatient with a prior allergic-like or unknown-type contrast reaction to the same
class of contrast medium who has arrived for a contrast-enhanced examination but has
not been premedicated and whose examination cannot be easily rescheduled.
2. Emergency department patient or inpatient with a prior allergic-like or unknown-
type contrast reaction to the same class of contrast medium in whom the use of 12- or
13-hour premedication is anticipated to adversely delay care decisions or treatment.
Specific Recommended Premedication
Regimens
 Elective Premedication (12- or 13-hour oral premedication)
1. Prednisone-based: 50 mg prednisone by mouth at 13 hours, 7 hours, and 1
hour before contrast medium administration, plus 50 mg diphenhydramine
intravenously, intramuscularly, or by mouth 1 hour before contrast medium
administration.
Or
2. Methylprednisolone-based: 32 mg methylprednisolone by mouth 12 hours
and 2 hours before contrast medium administration. 50 mg diphenhydramine
may be added as in option 1.
Specific Recommended
Premedication Regimens
 If a patient is unable to take oral medication, option 1 may be used.
 Substituting 200 mg hydrocortisone IV for each dose of oral prednisone. 
 If a patient is allergic to diphenhydramine in a situation where
diphenhydramine would otherwise be considered, 
 an alternate anti-histamine without cross-reactivity may be considered.
 or the anti-histamine portion of the regimen may be dropped.
Accelerated IV Premedication (in
decreasing order of desirability)
 Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or
hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV immediately, and
then every 4 hours until contrast medium administration, plus diphenhydramine 50
mg IV 1 hour before contrast medium administration.
 This regimen usually is 4-5 hours in duration.
 2. Dexamethasone sodium sulfate (e.g., Decadron®) 7.5 mg IV immediately, and
then every 4 hours until contrast medium administration, plus diphenhydramine 50
mg IV 1 hour before contrast medium administration.
 This regimen may be useful in patients with an allergy to methylprednisolone and is also
usually 4-5 hours in duration.
 3. Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or
hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV, plus
diphenhydramine 50 mg IV, each 1 hour before contrast medium administration.
Accelerated IV Premedication

 Any regimens with a duration less than 4-5 hours, has no evidence of efficacy.
It may be considered in emergent situations when there are no alternatives.
Missing One or More Doses of
Premedication
 Management should be individualized. 
 Generally speaking a guiding principle;
 Have a minimum of 4-5 hours of corticosteroid therapy prior to contrast medium
exposure with repeat doses every 4-8 hours. 
 Diphenhydramine administration is optional.
Premedication in Patients Undergoing
Chronic Corticosteroid Therapy
 Premedication dosing may be modified. 
  If corticosteroid premedication is being used, a guiding principle is to reduce
the dose of the chosen premedication dose regimen by an amount equivalent
to the patient’s chronic therapeutic corticosteroid dose. 
 If the patient is on simple replacement (not therapeutic) corticosteroids, the
premedication dosing regimen may not need to be adjusted.
Changing Contrast Media Within the
Same Class
 In patients with a prior allergic-like or unknown-type contrast reaction to a
known contrast medium, changing contrast media within the same class may
help reduce the likelihood of a subsequent contrast reaction.

combining premedication with a change in agent seems to have the greatest effect
Treatment 

 Treatment of acute adverse reactions to GBCM is similar to that for acute

reactions to iodinated contrast media
Treatment
EXTRAVASATION OF CONTRAST MEDIA

Frequency: 

Ranged from 0.1% to 1.2%.

Contrast injection rates have not been significantly
associated with the frequency of extravasation.
More common when injections are made into more
peripherally placed catheters.
Dynamic bolus CT may involve large volumes of contrast
media
Initial Signs and Symptoms

 Signs:
Initial swelling or tightness.
stinging or burning pain at the site of extravasation.
some little discomfort. 

 Physical examination:
the extravasation site may be edematous, erythematous, and tender. 
Sequelae of Extravasations

 Result in injury to surrounding tissues, particularly to the skin.

Acute local inflammatory response may not peak for 24 to 48 hours.

Mostly related to its hyperosmolality.

The vast majority of patients in whom extravasations occur recover without

significant sequelae.
severe injuries after extravasation of
LOCM
 Compartment syndromes.
Result from mechanical compression.
 May develop soon after an extravasation or result from increasing swelling that occurs
hours after the extravasation.
More likely to occur after extravasation of larger volumes of contrast media.
Or extravasation of relatively small volumes in less capacious areas 
 the ventral or dorsal surfaces of the wrist.
Less commonly injuries include skin ulceration and tissue necrosis.
Happen hours or days after
the extravasation event.
Evaluation

 A responsible health care provider should be summoned to examine any

patient in whom an extravasation of contrast material has occurred.
 History:
 symptoms of pain and paresthesias. 
 Examination 
 assessment of extremity tenderness, swelling, erythema, active and passive
range of motion of the fingers, and perfusion.
 AAll  extravasation  events  and  their  treatment  should  be documented  in  the 
medical  record, especially  in  the dictated imaging  report  of  the  obtained study. If 
the  extravasation  is  moderate  or  severe, the  referring  provider should be  notified. 
Extravasation of Gadolinium Based
Contrast Media
 Similar  to  lower  toxicity  in  comparison  to  iodinated  contrast agents .
 These agents usually  do  not  cause severe injury,  likely  due to  the
smaller  total volumes of  contrast  material  that  are  injected  at  MRI. 
Treatment

 Elevation  of  the  affected  extremity above the  level  of  the heart.
 Decrease  capillary  hydrostatic pressure  and  thereby.
 No scientific prove.
 Use warm or cold compresses.
 No  clear  evidence favoring  the use of warm or cold compresses or  vice versa.  
 Most surgeons will advise the use of cold compresses
 No  consistent  evidence that  local  injection  of  other  agents  such  as  corticosteroids  is 
beneficial.
  Aspiration is  not recommended. 
  Use of  hyaluronidase is not recommend. 
Outpatients

 Released  from  the radiology  department only  after  an initial  period  of 
observation. 
 Clear  instructions  should  be  given  to  the  patient  to  seek  additional
medical care,
 Any  worsening of  pain, swelling.
 Develop paresthesia
 Diminished range  of  motion of  the  fingers (active or passive)
 Skin ulceration, or  other  neurologic  or  circulatory  symptoms. 
Surgical Consultation

 An immediate  surgical  consultation is  indicated:

  Progressive  swelling  or  pain, 
 Altered tissue  perfusion
 Decreased  capillary  refill  at  any  time after  the extravasation  has 
occurred,  
 Change in  sensation  in  the affected limb
  Worsening  passive  or  active  range  of  motion of  the  elbow, wrist, or  fingers
 Skin ulceration or  blistering. 
Patients at Increased Risk for
Extravasations
 Those  who  cannot communicate  effectively
The  elderly, infants  and  children, and  patients with  altered  consciousness.
Severely ill or  debilitated  patients.
  Patients  with  abnormal circulation  in  the  limb  to  be  injected.
 atherosclerotic peripheral  vascular  disease,  diabetic vascular  disease, Raynaud’s 
disease, venous  thrombosis  or  insufficiency, or  prior  radiation  therapy  or  extensive 
surgery  (e.g., axillary  lymph node  dissection or  saphenous  vein graft  harvesting) .
 Certain intravenous access sites.
  Hand, wrist, foot,  and  ankle; more  likely  to  result  in extravasation and  should be  avoided,
if possible.
  Injection through indwelling  peripheral  intravenous  lines  that  have  been  in place  for more  than 24  hours 
and multiple  punctures  into the  same  vein are  associated with  an increased risk  of extravasation . 
Documentation

 All  extravasation  events  and  their  treatment  should  be documented  in 

the  medical  record, especially  in  the dictated imaging  report  of  the 
obtained study.
 If  the  extravasation  is  moderate  or  severe, the  referring  provider should
be  notified.